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Wibbenmeyer L, Lacey AM, Endorf FW, Logsetty S, Wagner ALL, Gibson ALF, Nygaard RM. American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite. J Burn Care Res 2024; 45:541-556. [PMID: 37045447 DOI: 10.1093/jbcr/irad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
This Clinical Practice Guideline addresses severe frostbite treatment. We defined severe frostbite as atmospheric cooling that results in a perfusion deficit to the extremities. We limited our review to adults and excluded cold contact or rapid freeze injuries that resulted in isolated devitalized tissue. After developing population, intervention, comparator, outcomes (PICO) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations based on the available scientific evidence were formulated through consensus of a multidisciplinary committee. We conditionally recommend the use of rapid rewarming in a 38 to 42°C water bath and the use of thrombolytics for fewer amputations and/or a more distal level of amputation. We conditionally recommend the use of "early" administration of thrombolytics (≤12 hours from rewarming) compared to "later" administration of thrombolytics for fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of vascular imaging studies to determine the use of and/or the time to initiate thrombolytic therapy. No recommendation could be formed on the use of intravenous thrombolytics compared to the use of intra-arterial thrombolytics on fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of iloprost resulting in fewer amputations and/or more distal levels of amputation. No recommendation could be formed on the use of diagnostic imaging modalities for surgical planning on fewer amputations, a more distal level of amputation, or earlier timing of amputation.
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Affiliation(s)
- Lucy Wibbenmeyer
- Department of Surgery, University of Iowa, Iowa City, IA 52242, USA
| | | | | | - Sarvesh Logsetty
- Departments of Surgery, Psychiatry, and Children's Health, University of Manitoba, Winnipeg, Manitoba R3E 3P5, Canada
| | - Anne L L Wagner
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - Rachel M Nygaard
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN 55415, USA
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Öner Ç, Irmak F, Eken G, Öner BB, Karsıdağ SH. The effect of stromal vascular fraction in an experimental frostbite injury model. Burns 2023; 49:149-161. [PMID: 35241296 DOI: 10.1016/j.burns.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/29/2022] [Accepted: 02/14/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Despite current treatment modalities, frostbite remains an injury with a poor prognosis which may cause functional morbidities. Several experimental and clinical studies have demonstrated that stromal vascular fraction is an autologous mixture, which can improve wound healing and vasculogenesis. The aim of this study was to show the beneficial effects of stromal vascular fraction on experimental frostbite healing. MATERIAL AND METHODS Stromal vascular fraction (SVF) was harvested from 5 rats after excision of the inguinal fat pads. Another 20 rats were separated into 2 groups of 10 as the SVF group and the control group. A frostbite injury was created on each rat using a cryoprobe frozen with liquid nitrogen (-196 °C). SVF was applied to the SVF group and phosphate-buffered saline to the control group. All injections were performed subcutaneously within the frostbite injury area. Biopsies were performed on days 5 and 14 for histopathological and immunochemical evaluations. The tissue perfusion rates of both groups were assessed on day 14 using indocyanine green angiography (SPY system). RESULTS The increase in mean tissue perfusion was 373.3% ( ± 32.1) in the SVF group and 123.8% ( ± 16.3) in the control group (p < 0.001). The macroscopic wound reduction rates of the SVF and control groups were 25.5% ( ± 19.1) and 18.0% ( ± 5.9), respectively on day 5%, and 78.2% ( ± 9.2) and 57.3% ( ± 16.7) on day 14 (p = 0.007; p = 0.003). Acute inflammation and the fibrosis gradient were significantly decreased in the SVF group compared to the control group (p = 0.004, p = 0.054 respectively on day 14). Granulation tissue amount, re-epithelialization score and neovascularization were significantly increased in the SVF group (p = 0.006, p = 0.010 and p = 0.021, respectively on day 14). CONCLUSIONS The study results demonstrated that SVF increases frostbite wound healing by increasing tissue perfusion rate, neovascularization and re-epithelialization, and modulating acute inflammation and fibrosis.
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Affiliation(s)
- Çağatay Öner
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey; Department of Plastic, Reconstructive and Aesthetic Surgery, Sirnak State Hospital, Sirnak, Turkey.
| | - Fatih Irmak
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.
| | - Gülçin Eken
- Department of Clinical Pathology, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.
| | - Burcu Bitir Öner
- Department of Anesthesiology and Reanimation, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.
| | - Semra Hacıkerim Karsıdağ
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.
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Shupp JW, Holmes JH, Moffatt LT, Phelan HA, Sousse L, Romanowski KS, Jeschke M, Kowalske KJ, Badger K, Allely R, Cartotto R, Burmeister DM, Kubasiak JC, Wolf SE, Wallace KF, Gillenwater J, Schneider DM, Hultman CS, Wiechman SA, Bailey JK, Powell HM, Travis TE, Supp DM, Carney BC, Johnson LS, Johnson LS, Chung KK, Chung KK, Kahn SA, Gibson ALF, Christy RJ, Carter JE, Carson JS, Palmieri TL, Kopari NM, Blome-Eberwein SA, Hickerson WL, Parry I, Cancio JM, Suman O, Schulman CI, Lamendella R, Hill DM, Wibbenmeyer LA, Nygaard RM, Wagner AL, Carter ADW, Greenhalgh DG, Lawless MB, Carlson DL, Harrington DT. Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting. J Burn Care Res 2022; 43:1241-1259. [PMID: 35988021 DOI: 10.1093/jbcr/irac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.
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Rogers C, Lacey AM, Endorf FW, Gopal P, Whitley A, Gayken J, Fey R, Schmitz K, Nygaard RM. The Effects Of Rapid Rewarming On Tissue Salvage In Severe Frostbite Injury. J Burn Care Res 2021; 43:906-911. [PMID: 34791315 DOI: 10.1093/jbcr/irab218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Frostbite is a high morbidity injury caused by soft tissue freezing, which can lead to digit necrosis requiring amputation. Rapid rewarming is a first line treatment method that involves placing affected digits into a warm water bath. This study aims to assess the clinical practices for frostbite at facilities outside of dedicated burn centers, and any impact these practices have on tissue salvage. Retrospective chart review at a single burn center identified frostbite patients admitted directly or as transfers over a seven-year period. Records were reviewed to identify initial treatment strategies. If given, time to thrombolytics from admit was noted. Tissue salvage rates were calculated from radiologically derived tissue at-risk scores and final amputation scores. One-hundred patients were transferred from outside facilities, and 108 were direct admissions (N=208). There was no significant difference in group demographics. Rapid rewarming was the initial treatment modality more commonly in direct admit patients (P=0.016). The use of rapid rewarming did not correlate with tissue salvage (P=0.112). Early use of thrombolytics had a positive impact on tissue salvage (P=0.003). Thrombolytics were given 1.2 hours earlier in direct admit patients (P=0.029), however there was no difference in tissue salvage rates between the groups (P=0.127). Efforts should focus on larger scale study to further assess the effectiveness of rapid rewarming. Although rapid rewarming did not significantly impact tissue salvage in this study, we continue to recommend its use over less studied treatment methods, and continue to view it as an important bridge to burn center transfer and administration of thrombolytic therapy.
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Affiliation(s)
| | | | | | - Punjabi Gopal
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Angela Whitley
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Jon Gayken
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Ryan Fey
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Kyle Schmitz
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
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Ding C, Zhou C, Fan Y, Liu Q, Zhang H, Wu Z. Electrospun polylactic acid/sulfadiazine sodium/proteinase nanofibers and their applications in treating frostbite. J Appl Polym Sci 2021. [DOI: 10.1002/app.51716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Chengbiao Ding
- Department of Rehabilitation Medicine The Second Hospital of Anhui Medical University Hefei Anhui China
- School of Nuclear Science and Technology University of Science and Technology of China Hefei China
| | - Chenxu Zhou
- Department of Rehabilitation Medicine The Second Hospital of Anhui Medical University Hefei Anhui China
| | - Yueyao Fan
- School of Nuclear Science and Technology University of Science and Technology of China Hefei China
| | - Qi Liu
- School of Nuclear Science and Technology University of Science and Technology of China Hefei China
| | - Haifeng Zhang
- School of Nuclear Science and Technology University of Science and Technology of China Hefei China
| | - Zhengwei Wu
- School of Nuclear Science and Technology University of Science and Technology of China Hefei China
- CAS Key Laboratory of Geospace Environment University of Science and Technology of China Hefei China
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Joshi K, Goyary D, Mazumder B, Chattopadhyay P, Chakraborty R, Bhutia YD, Karmakar S, Dwivedi SK. Frostbite: Current status and advancements in therapeutics. J Therm Biol 2020; 93:102716. [PMID: 33077129 DOI: 10.1016/j.jtherbio.2020.102716] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 01/02/2023]
Abstract
Frostbite is a severe ischemic injury which occurs due to the tissue vascular damage after sub-zero temperature tissue exposure. Deep frostbite can result in necrosis and may need amputation of affected tissue. Though a serious injury, it is not very well understood, and further scientific exploration is needed. This work explores the current understanding of the pathophysiology of frostbite. We reviewed the current status of the diagnostics, the drugs, the therapies and the surgical practices for prevention and management of frostbite. Advances in nanotechnology and drug delivery had improved the therapeutic outcomes significantly. This review also explored the latest advancements and researches done for development of newer therapeutics and diagnostics for frostbite care.
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Affiliation(s)
- Kumud Joshi
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India; Department of Pharmaceutical Sciences, Dibrugarh University, Assam, India
| | - Danswrang Goyary
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India.
| | - Bhaskar Mazumder
- Department of Pharmaceutical Sciences, Dibrugarh University, Assam, India
| | | | - Reshmi Chakraborty
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Y D Bhutia
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Sanjeev Karmakar
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Sanjai Kumar Dwivedi
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
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Hickey S, Whitson A, Jones L, Wibbenmeyer L, Ryan C, Fey R, Litt J, Fabia R, Cancio L, Mohr W, Twomey J, Wagner A, Cochran A, Bailey JK. Guidelines for Thrombolytic Therapy for Frostbite. J Burn Care Res 2020; 41:176-183. [DOI: 10.1093/jbcr/irz148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
The data are insufficient to support standardized treatment of all patients with frostbite with thrombolytic therapy. The following guidelines, however, should be applied to all patients with cyanosis persisting proximal to the distal phalanx (Grade 3 or 4 frostbite injury) and demonstrated loss of perfusion at or proximal to the middle phalanx immediately after rewarming.
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Affiliation(s)
- Sean Hickey
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy Whitson
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Larry Jones
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Lucy Wibbenmeyer
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City
| | - Colleen Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School Shriners Hospitals for Children-Boston
| | - Ryan Fey
- Department of Surgery, Hennepin County Medical Center, Minneapolis Minnesota
| | - Jeffrey Litt
- Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri
| | - Renata Fabia
- Department of Pediatric Surgery, Nationwide Childrens Hospital, Columbus, Ohio
| | - Lee Cancio
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - William Mohr
- Burn Center and Department of Trauma and General Surgery, Regions Hospital, St. Paul, Minnesota
- Department of Surgery, University of Minnesota, Minneapolis
| | - John Twomey
- Department of Surgey, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Anne Wagner
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Amalia Cochran
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - J Kevin Bailey
- Department of Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina
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Use of Intra-arterial Thrombolytic Therapy for Acute Treatment of Frostbite in 62 Patients with Review of Thrombolytic Therapy in Frostbite. J Burn Care Res 2018; 37:e323-34. [PMID: 25950290 PMCID: PMC4933583 DOI: 10.1097/bcr.0000000000000245] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Amputations are common after severe frostbite injuries, often mediated by postinjury arterial thrombosis. Since 1994, the authors have performed angiography to identify perfusion deficits in severely frostbitten digits and treated these lesions with intraarterial infusion of thrombolytic agents, usually combined with papaverine to reduce vasospasm. A retrospective review was performed of patients admitted to the regional burn center with frostbite injury from 1994 to 2007. Patients with severe frostbite, without contraindications to thrombolytic therapy, underwent diagnostic angiography of the affected extremities. Limbs with perfusion defects received intraarterial thrombolytic therapy according to protocol and the response was documented. Delayed amputation was performed for mummified digits. Angiogram results and amputation rates were tabulated. In this 14-year review, 114 patients were admitted for frostbite injuries. There was a male predominance (84%) and the mean age was 40.4 years. Of this group, 69 patients with severe frostbite underwent angiography; 66 were treated with intraarterial thrombolytic therapy. Four treated were excluded due to incomplete data. In the remaining 62 patients, angiography identified 472 digits with frostbite injury and impaired arterial perfusion. At the termination of thrombolytic infusion, a completion angiogram was performed. Partial or complete amputations were performed on only four of 198 digits (2.0%) with distal vascular blush, and in 71 of 75 digits (94.7%) with no improvement. Amputations occurred in 73 of 199 digits (36.7%) with partially restored flow. Overall complete digit salvage rate was 68.6%. Angiography after severe frostbite is a sensitive method to detect impaired arterial blood flow and permits catheter-directed treatment with thrombolytic agents. Improved perfusion after such treatment decreases late amputations following frostbite injury.
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Intra-arterial Thrombolysis for Extremity Frostbite Decreases Digital Amputation Rates and Hospital Length of Stay. Cardiovasc Intervent Radiol 2017; 40:1824-1831. [PMID: 28702681 DOI: 10.1007/s00270-017-1729-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To report outcomes of intra-arterial thrombolysis versus non-thrombolytic management of severe frostbite with respect to digital amputation rates and hospital length of stay (LOS). MATERIALS AND METHODS Seventeen patients with severe frostbite were identified from 2000 to 2017. Eight (47%) patients with mean age of 40 years underwent intra-arterial thrombolysis and served as the treatment group. Nine (53%) patients with mean age of 53 years received non-thrombolytic management and served as the control group. 2/8 (25%) treatment and 3/9 (33%) control patients had underlying vascular comorbidities (p = 0.25). Number of digits at risk, duration of thrombolysis, thrombolytic agents used, digits amputated, hospital LOS, and complications were recorded. RESULTS Seven upper and nine lower extremities for a total of 80 digits were at risk in the treatment cohort. Eight upper and 12 lower extremities for a total of 100 digits were at risk in the control group. Mean duration of thrombolysis was 26 h. All treatment patients received tissue plasminogen activator in addition to systemic heparin. 4/16 (25%) limbs received intra-arterial alprostadil, 2/16 (13%) received nitroglycerin, and 2/16 (13%) received nicardipine. 12/80 (15%) treatment digits and 77/100 (77%) control digits required amputation (p = 0.003). Average hospital LOS was 14 days in the treatment group and 38 days in the control group (p = 0.011). No major complications occurred in the treatment group; however, 2/9 (22%) patients in the control group required extended hospitalizations secondary to amputation complications. CONCLUSIONS Intra-arterial thrombolysis reduces digital amputation rates and hospital LOS in the setting of severe frostbite.
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Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns 2017; 43:1088-1096. [PMID: 28159151 DOI: 10.1016/j.burns.2017.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/02/2016] [Accepted: 01/07/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE tPA and anticoagulation for treatment of severe frostbite have been reported suggesting differences in imaging techniques, route of tPA administration and management of patients after tPA infusion. This is a report of our results following a protocol of Tc-99m scanning, intravenous tPA administration, followed by either systemic anticoagulation or antiplatelet therapy. METHODS Patients admitted to our burn center between February 13, 2015 and February 13, 2016 for frostbite who met inclusion criteria were treated with Tc-99m scan and intravenous tPA followed by systemic anticoagulation or antiplatelet therapy. Inclusion criteria included rewarming had not started more than 24h prior to the scan and no contraindications to the use of tPA. RESULTS Fifteen patients met inclusion criteria and 12 were treated according to the protocol. Nine received scans with 2 showing normal perfusion. Seven displayed perfusion defects and received intravenous tPA. Five recovered fully after tPA. Two who showed improved but abnormal scans after tPA experienced bleeding complications necessitating stopping heparin/Coumadin. Those two went on to partial amputation of digits. CONCLUSION The use of intra-arterial or intravenous tPA along with angiography or Tc-99m scanning followed by systemic anticoagulation or antiplatelet therapy may be beneficial to patients suffering frostbite.
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Affiliation(s)
- Larry M Jones
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Rebecca A Coffey
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Mona P Natwa
- Department of Radiology, Division of Nuclear Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - J Kevin Bailey
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
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Heil K, Thomas R, Robertson G, Porter A, Milner R, Wood A. Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull 2016; 117:79-93. [PMID: 26872856 DOI: 10.1093/bmb/ldw001] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2015] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The debilitating impact of cold weather on the human body is one of the world's oldest recorded injuries. The severe and life-changing damage which can be caused is now more commonly seen recreationally in extreme outdoor sports rather than in occupational settings such as the military. The diagnosis and treatment of these injuries need to be completed carefully but quickly to reduce the risk of loss of limb and possibly life. Therefore, we have conducted a systematic review of the literature surrounding cold weather injuries (CWIs) to ascertain the epidemiology and current management strategies. SOURCES OF DATA Medline (PubMED), EMBASE, CINHAL, Cochrane Collaboration Database, Web of Science, Scopus and Google Scholar. AREAS OF AGREEMENT IMMEDIATE FIELD TREATMENT The risk of freeze thaw freeze injuries. Delayed surgical intervention when possible. Different epidemiology of freezing and non-freezing injuries. AREAS OF CONTROVERSY Prophylatic use of antibiotics; the use of vasodilators surgical and medical. GROWING POINTS The use of ilioprost and PFG2a for the treatment of deep frostbite. AREAS TIMELY FOR DEVELOPING RESEARCH The treatment of non-freezing CWIs with their long-term follow-up.
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Affiliation(s)
| | | | - Greg Robertson
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Anna Porter
- Newcastle University, Newcastle upon Tyne, UK
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The Emerging Role of Tissue Plasminogen Activator in the Management of Severe Frostbite. J Burn Care Res 2015; 36:e62-6. [DOI: 10.1097/bcr.0000000000000135] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L, Cochran A, Imray CH. Frostbite: a practical approach to hospital management. EXTREME PHYSIOLOGY & MEDICINE 2014; 3:7. [PMID: 24764516 PMCID: PMC3994495 DOI: 10.1186/2046-7648-3-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/24/2014] [Indexed: 11/18/2022]
Abstract
Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost. In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians.
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Affiliation(s)
| | - Pauline Buxton
- University Hospital Coventry & Warwickshire, Coventry CV2 2DX, UK
| | | | | | - Scott E McIntosh
- Division of Emergency Medicine, University of Utah Health Care, Salt Lake City, UT 84112, USA
| | - Luanne Freer
- FAWM, Yellowstone National Park, WY 82190, USA ; Everest ER, Himalayan Rescue Association, P.O. Box 4944, Kathmandu 44601, Nepal
| | - Amalia Cochran
- University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Christopher He Imray
- Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK ; University Hospital Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
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Suhag GS, Bhatnagar A, Singh H. Poly(hydroxyethyl methacrylate)-based co-polymeric hydrogels for transdermal delivery of salbutamol sulphate. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2012; 19:1189-200. [DOI: 10.1163/156856208785540118] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Geeta Singh Suhag
- a Centre for Biomedical Engineering, Indian Institute of Technology, Delhi, India
| | - Aseem Bhatnagar
- b Institute of Nuclear Medicine and Allied Sciences, DRDO, Delhi, India
| | - Harpal Singh
- c Centre for Biomedical Engineering, Indian Institute of Technology, Delhi, India
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Wagner C, Pannucci CJ. Thrombolytic therapy in the acute management of frostbite injuries. Air Med J 2011; 30:39-44. [PMID: 21211711 DOI: 10.1016/j.amj.2010.08.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Saemi AM, Johnson JM, Morris CS. Treatment of Bilateral Hand Frostbite Using Transcatheter Arterial Thrombolysis After Papaverine Infusion. Cardiovasc Intervent Radiol 2009; 32:1280-3. [DOI: 10.1007/s00270-009-9584-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 03/24/2009] [Accepted: 04/07/2009] [Indexed: 10/20/2022]
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Twomey JA, Peltier GL, Zera RT. An Open-Label Study to Evaluate the Safety and Efficacy of Tissue Plasminogen Activator in Treatment of Severe Frostbite. ACTA ACUST UNITED AC 2005; 59:1350-4; discussion 1354-5. [PMID: 16394908 DOI: 10.1097/01.ta.0000195517.50778.2e] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe frostbite can have devastating consequences with loss of limbs and digits. One of the mechanisms of cold injury to human tissue is vascular thrombosis. The effect of tissue plasminogen activator (tPA) and heparin in limb and digit preservation in severe frostbite patients has not been previously studied. METHODS Intra-arterial (6 patients) or intravenous (i.v., 13 patients) tPA and IV heparin were used in patients with severe frostbite. All patients between January 1, 1989 and February 1, 2003 with severe frostbite not improved by rapid rewarming, with absent Doppler pulses in distal limb or digits, without perfusion by Technetium (Tc) 99m three-phase bone scan, and no contraindication to tPA use were eligible. Efficacy was assessed on the basis of predicted digit amputation before therapy, given the clinical and Tc-99m scan results, versus partial or complete digits removed. RESULTS There were no complications with i.v. tPA. Two patients with intra-arterial TPA had bleeding complications. We know from historical Tc-99m scan data which digits were at risk for amputation. In this study, there were 174 digits at risk in 18 patients and only 33 were amputated. CONCLUSION Intravenous tPA and heparin after rapid rewarming is safe and reduced predicted digit amputations considerably. Patients with no response to thrombolytic therapy were those with more than 24 hours of cold exposure, warm ischemia times greater than 6 hours, or evidence of multiple freeze-thaw cycles. Our algorithm for treatment of severe frostbite now includes use of i.v. tPA for patients without contraindications.
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Affiliation(s)
- John A Twomey
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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The pathology of high altitude: an introduction to the disease states of high altitude. ACTA ACUST UNITED AC 2000. [DOI: 10.1054/cacc.2000.0243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. THE JOURNAL OF TRAUMA 2000; 48:171-8. [PMID: 10647591 DOI: 10.1097/00005373-200001000-00036] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Frostbite, once almost exclusively a military problem, is becoming more prevalent among the general population and should now be considered to be within the scope of the civilian physician's practice. Studies into the epidemiology of civilian frostbite have identified several risk factors that may aid the clinician in the diagnosis and management of cold injuries. Research into the pathophysiology has revealed marked similarities in inflammatory processes to those seen in thermal burns and ischemia/reperfusion injury. Evidence of the role of thromboxanes and prostaglandins has resulted in more active approaches to the medical treatment of frostbite wounds. Although the surgical management of frostbite involves delayed debridement 1 to 3 months after demarcation, recent improvements in radiologic assessment of tissue viability have led to the possibility of earlier surgical intervention. In addition, several adjunctive therapies, including vasodilators, thrombolysis, hyperbaric oxygen, and sympathectomy, are discussed.
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Affiliation(s)
- J V Murphy
- Burns and Reconstructive Surgery Research Trust, Stoke Mandeville Hospital, United Kingdom
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Ozyazgan I, Tercan M, Melli M, Bekerecioğlu M, Ustün H, Günay GK. Eicosanoids and inflammatory cells in frostbitten tissue: prostacyclin, thromboxane, polymorphonuclear leukocytes, and mast cells. Plast Reconstr Surg 1998; 101:1881-6. [PMID: 9623831 DOI: 10.1097/00006534-199806000-00016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pathophysiology of cold injury is still controversial. An inflammatory process has been implicated as the underlying mechanism and certain anti-inflammatory substances such as ibuprofen and acetylsalicylic acid have been used in the clinical treatment of frostbite injury. It has been postulated that the progressive ischemic necrosis is secondary to excessive thromboxane A2 production, which upsets the normal balance between prostacyclin (prostaglandin I2) and thromboxane A2. It was aimed to clarify the pathophysiology of cold injury in this study. Twenty-one New Zealand White rabbits, each weighing 1.2 to 2.9 kg, were divided into control (n = 10) and frostbitten (n = 11) groups the randomly. The rabbit ears in the frostbitten group were subjected to cold injury, and the levels of thromboxane A2 (as thromboxane B2) and of prostaglandin I2 (as 6-keto-prostaglandin F1alpha) and the number of inflammatory cells (polymorphonuclear leukocytes and mast cells) were measured in normal and frostbitten skin of rabbit ears. The levels of 6-keto prostaglandin F1alpha and thromboxane B2, the stable metabolites of prostaglandin I2 and thromboxane A2, respectively, were increased in a statistically significant way (p < 0.002) by frostbite injury; however, thromboxane B2 increased more than 6-keto prostaglandin F1alpha. Polymorphonuclear leukocytes and mast cells, absent in normal skin, were present in the frostbitten skin. There was a statistically significant (p < 0.01) correlation between the time a rabbit ear was maintained at below -10 degrees C and skin survival and between the weights of rabbits and skin survival (p < 0.024). All these findings suggest that inflammation is involved in frostbite injury; a decrease in prostaglandin I2/thromboxane A2 ratio could be one of the factors leading to necrosis; the bigger the animal, the better its ability to counter frostbite.
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Affiliation(s)
- I Ozyazgan
- Department of Plastic and Reconstructive Surgery at Erciyes University, Kayseri, Turkey
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Junila J. Changes in adrenergic nerves and tissue perfusion after freezing injury to the ear skin of rabbits. SCANDINAVIAN JOURNAL OF PLASTIC AND RECONSTRUCTIVE SURGERY AND HAND SURGERY 1993; 27:173-8. [PMID: 8272767 DOI: 10.3109/02844319309078108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The aim of the present study was to investigate by a combined trypan blue and catecholamine fluorescence technique the sequential changes in cutaneous adrenergic nerves, the distribution of blood flow, and vascular permeability at the demarcation line that occurred after experimental cold injury. Nine New Zealand white rabbits weighing 4.0-4.4 kg had frostbite induced by pressing the bottom of a glass bottle 2 cm in diameter filled with liquid nitrogen against the shaved skin of the ear. All the rabbits were anaesthetised with ketamine hydrochloride (Ketamine) and xylazine hydrochloride (Rompun). Specimens were taken one and three days, and two weeks after frostbite. Control samples were taken from the opposite normal ear. Trypan blue was injected into a saphenous vein just before the specimens were taken. The specimens were always taken in the same way and selected so that the probable demarcation line of the frostbite ran across the middle. The glyoxylic acid-induced fluorescence method was used to show the adrenergic nerves. There were no adrenergic nerves around the vessels and no arteriovenous anastomoses in the central area of the injury after one day, but catecholamines had started to accumulate in the adrenergic nerve endings at the margins of the injured area. This accumulation was still more obvious three days after frostbite. Some fluorescent regenerating adrenergic nerves could already be seen at the probable demarcation line two weeks after frostbite. There was increased trypan blue fluorescence near the margin of the injured area after one day, indicating extravasation and vascular damage.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Junila
- Department of Surgery, Oulu University Central Hospital, Finland
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Britt LD, Dascombe WH, Rodriguez A. New horizons in management of hypothermia and frostbite injury. Surg Clin North Am 1991; 71:345-70. [PMID: 2003255 DOI: 10.1016/s0039-6109(16)45384-3] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diagnosing hypothermia requires a high index of suspicion. Restoring lost heat with careful attention to hemodynamics usually results in complete recovery. Frostbite is best treated by physicians who are cognizant of the pathophysiology of cold injury. Although alternative methods of intervention are being tested, rapid rewarming and anti-inflammatory agents are integral to treatment protocols.
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Affiliation(s)
- L D Britt
- Shock Trauma Center, Sentara Norfolk General Hospital, Virginia
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